Autumn Care Of Myrtle Grove
Autumn Care of Myrtle Grove in Wilmington, NC — inspection on April 24, 2025.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Meetings.
The Administrator stated the previous Social Services Director left the facility a few
addressing the concerns that were expressed at the meetings.
The Administrator acknowledged he
members and he should have addressed the concern forms that were given to him.
The Administrator had no documentation that showed that the grievances reported during the monthly Resident Council meetings for the past 6 months were addressed.
The Administrator acknowledged he signed the monthly meeting minutes but was unable to explain if he was aware of the repeated concerns expressed as the meetings.
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Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412
immediate jeopardy removal date of 4/25/25 was validated.
jeopardy to resident health or safety
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Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412
convey specific information when a resident is transferred or discharged.
record review and staff interview, the facility failed to communicate all required information to the
The findings included: Resident #1 was admitted to the facility on [DATE] with diagnoses that included cerebral infarction due to occlusion or stenosis of left middle cerebral artery (stroke), dysphagia (difficulty swallowing), and aphasia (absence of speech).
The physician's orders for Resident #1 dated 1/14/25 included a jejunostomy tube (a surgically placed feeding tube that delivers nutrition and medications directly into the small intestine) 16 French (size).
The admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 was severely cognitively impaired and had no speech.
A nurse's progress note written by the Director of Nursing on 1/25/25 at 2:00 PM indicated that she received a call from the floor nurse that Resident #1's jejunostomy tube (j-tube) fell out.
Nurse #1 was advised to call the Provider on call and send to the hospital or placement of j-tube.
An incomplete 2-page Hospital Transfer Form for Resident #1 listed the following information on page 1: His name, date of admission, date of birth , and primary diagnosis. It further listed the Responsible Party was notified of the situation and of the transfer to the hospital.
The reason for the transfer was listed as pulled out j-tube.
The form indicated that Resident #1 was alert, disoriented, could not follow/simple commands, he required a proxy for decision making capacity, he was incontinent of bowel and bladder, and the date of his last bowel movement was noted.
Page 1 of the form was missing the code status, relevant diagnoses, and functional status. On page 2 of the form the risk alert boxes for anticoagulation, aspiration, high fall risk, needs medications crushed, and pain level were checked.
His diet was listed as enteral feeding.
The sections for respiratory, medications, devices, isolation precautions, and vital signs were not completed.
The form was not signed and dated.
An interview with Nurse #1 was completed on 4/23/25 at 10:00 AM.
Nurse #1 stated she was the nurse assigned to care for Resident #1 on 1/25/25 when his j-tube became dislodged.
She further stated the residents she was assigned to care for that day were high acuity (residents requiring closer monitoring and treatments with i.e. tracheostomy tubes, feeding tubes, wounds) and she had not completed the documentation related to the incident.
Nurse #1 indicated that the Director of Nursing (DON) called her multiple times to return to the facility to complete the paperwork, but she never went back to the facility.
An interview with the DON was completed on 4/23/25 at 4:00 PM.
The DON stated she tried to call Nurse #1 multiple times to get her to come back to the facility to complete the paperwork regarding Resident #1's transfer to the hospital, but she never came back.
She indicated she expected the nursing staff documentation to be complete and accurate.
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Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412
feeding tubes verified there were no other residents with j-tubes identified.
The education sign in
jeopardy to resident health or regarding enteral feeding tubes policy and what to do if a j-tube becomes dislodged.
Staff interviews safety confirmed education on gastrostomy tubes, j-tubes, and what to do if a jejunostomy becomes dislodged.
The DON stated on 4/24/25 at 12:22 PM stated that effective 4/24/25 the DON or ADON
pending weekend admissions, to determine if any admissions have a j-tube present and ensure all licensed nursing staff are made aware of the presence of a j-tube and the process of physician notification and treatment if a j-tube becomes dislodged.
The facility's immediate jeopardy removal date of 4/25/25 was validated.
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Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412
jeopardy to resident health or feeding tubes verified there were no other residents with j-tubes identified.
The educations sign in safety sheets were reviewed for in-services conducted with the nurses on 4/23/25 and 4/24/25 regarding the facility's Gastrostomy Tube Reinsertion Policy which included education regarding what to do if a
risks involved in reinsertion, and sending the resident to the hospital for surgical reinsertion.
Staff interviews confirmed education and a quiz on gastrostomy tubes, j-tubes, and what to do if a jejunostomy becomes dislodged.
The validation quizzes were reviewed with no concerns.
The DON stated on 4/24/25 at 12:22 PM that all the nurses, including new hires and agency nurses, would have to pass the validation quiz for competency regarding feeding tubes.
The facility's immediate jeopardy removal date of 4/25/25 was validated.
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Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412
indicated since that time she had provided education to staff regarding medication administration and
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Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412
During an interview on 4/24/25 at 1:00 PM the Unit Manger stated Resident #3's urine sample was obtained on 4/15/25 by Nurse #4 and the order was entered into the electronic medical record and into the lab services database to collect the urine.
She stated the process included that once the order was entered into the residents medical record by the nurse, the nurse then had to enter the order into the lab services website and print a requisition form (informs the lab of what tests to perform) and then record it in the lab book which was kept at the nurses station.
When the lab company comes to the facility they review the lab book to determine what needed to be collected.
She stated the breakdown was that the order was not entered into the lab book therefore the lab did not pick up the urine sample.
She indicated she usually checked the lab book to ensure the labs were recorded.
She stated it was done in error.
During an interview on 4/24/25 at 2:00 PM the Director of Nursing stated she was not aware of the urine sample obtained for urinalysis not being picked up from the lab for Resident #3.
She stated a process was in place for obtaining labs and the process was not followed.
She stated once the lab order was entered into the resident's medical record it also had to be written in the lab book and that was not done.
She stated education would be provided.
During an interview on 4/24/25 at 3:00 PM Physician #2 stated she was made aware of the urinalysis not being collected today.
She indicated there had been no significant outcome from not obtaining the urinalysis with culture and sensitivity.
She stated Resident #3 remained on antibiotics for urinary tract infection and she expected lab orders to be entered correctly, and results made available and that was not done.
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Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412
Findings included. 1.) Resident #1 was admitted to the facility on [DATE].
The physician's orders for Resident #1 revealed orders dated 1/14/25 for: - a jejunostomy tube (a surgically placed feeding tube that delivers nutrition and medications directly into the small intestine) 16 French (size) - tube feeding at a continuous rate of 70 milliliters (ml) an hour for 22 hours to allow for activities of daily living - amlodipine (used to treat high blood pressure) 5 milligrams (mg) tablet per feeding tube, once a day for hypertension (high blood pressure) - cetirizine 10 mg tablet once a day per feeding tube for seasonal allergies - apixaban 5 mg tablet twice a day per feeding tube for anticoagulant (blood thinner) - loratadine 10 mg tablet once a day for allergies The January 2025 Medication Administration Record (MAR) for Resident #1 listed Eliquis, Loratadine, Amlodipine, and Cetirizine as administered via j-tube by Nurse #1 on 1/25/25 during the 7:00 AM to 11:00 AM medication pass.
A partially filled out SBAR (Situation, Background, Appearance, Review and Notify is a structured communication tool used to transmit clear concise information) 4 page form in the chart dated 1/25/25 and signed by Nurse #1 listed the Situation was: The change in condition, symptoms, or signs observed and evaluated were Resident #1 pulling out his jejunostomy tube (j-tube) twice and the condition was listed as occurring before due to resident consistently playing and tugging on the tube.
In the section under Background: the box was checked that the resident was in the facility for long-term care.
The areas that were not completed were the primary diagnosis, other pertinent history, Medication Alerts for changes, anticoagulants, hypoglycemics, allergies, and vital signs including pulse oximetry (measures the oxygen saturation in the blood cells).
The Resident Evaluation was not completed regarding his mental and functional status, behavioral evaluation, respiratory evaluation, cardiovascular evaluation, abdominal/gastrointestinal (GI) evaluation, Genitourinary/Urine evaluation, skin evaluation, pain evaluation, neurological evaluation, and care plan information.
There was a box at the top of the evaluations to check if the area was not clinically applicable to the change in the condition being reported.
The Section regarding Appearance was not filled out. In the section to Review and Notify the box to call for 911 for transfer to the hospital was checked. Resident #1's name was listed on the form, the Responsible Party (RP) was notified at 12:51 PM, the on-call provider was notified at 1:12 PM and the form was signed and dated by Nurse #1 on 1/25/25 at 12:51
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Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412
F 0842 PM.
stated the residents she was assigned to care for that day were high acuity (residents requiring
not completed the documentation related to the incident.
Nurse #1 indicated that the Director of Nursing (DON) called her multiple times to return to the facility to complete the paperwork, but she never went back to the facility.
Nurse #1 also stated she did not administer Eliquis, Loratadine, Amlodipine, and Cetirizine to Resident #1 on 1/25/25 during the 7:00 AM to 11:00 AM medication pass.
She stated that she must have checked the medications off on the MAR as administered when she pulled them from the medication cart, but she did not administer the medications.
An interview with the DON was completed on 4/23/25 at 4:00 PM.
The DON stated she tried to call Nurse #1 multiple times to get her to come back to the facility to complete the paperwork regarding Resident #1's transfer to the hospital, but she never came back.
She indicated she expected the nursing staff documentation to be complete and accurate. 2.) Resident #4 was admitted to the facility on [DATE] with diagnoses including diabetes.
A physician's order for Resident #4 dated 1/6/25 and discontinued on 1/31/25 revealed Humulin R Regular insulin U-100 insulin 100units per milliliter.
Administer per sliding scale as follows: No sliding scale coverage for blood sugar less than 150.
Review of the Medication Administration Record (MAR) dated January 2025 for Resident #4 revealed Humulin R sliding scale insulin was signed off by Nurse #1 as 0 (zero) units administered at 11:00 AM on 1/25/25.
The blood sugar reading was 103.
During a phone interview on 4/23/25 at 9:10 AM Nurse #1 stated she administered insulin to Resident #4 in error on 1/25/25.
She stated on 1/25/25 she checked Resident #4's blood sugar and recalled his blood sugar was in the low 90's or 100's.
She stated she went back to the medication cart and three nurse aides approached her with problems which distracted her.
She then drew up 2 units of insulin and administered it to Resident #4.
Once she administered the insulin the family stated they thought he didn't need insulin, and she realized then that he wasn't supposed to get the 2 units that she had just administered.
Nurse #1 stated if she documented 0 (zero) units administered then it was signed in error because she did give 2 units of insulin at 11:00 AM on 1/25/25.
She stated she should have documented that 2 units of insulin was administered to Resident #4.
During an interview on 4/23/25 at 2:00 PM the Director of Nursing (DON) stated she was made aware of the medication error by Nurse #1 on 1/25/25.
She stated Nurse #1 should not have administered Resident #4 sliding scale insulin with a blood sugar reading less than 150 and she was not aware that she documented in error on the MAR.
She stated Nurse #1 should have documented on the MAR that she administered 2 units of insulin to Resident #4.
She indicated education would be provided regarding accurately documenting in the medical record.
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Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412
During an interview on 4/22/25 at 5:00 PM Nurse #3 stated she should have put on a gown along with the gloves and mask before providing Resident 5#'s tracheostomy care.
She stated she had received education on Enhanced Barrier Precautions and using personal protective equipment.
She stated it was done in error.
During an interview with the Infection Control Preventionist Nurse on 4/23/25 at 11:00 AM she stated Resident #5 was on Enhanced Barrier Precautions due to having a tracheostomy.
She indicated a sign was located outside of Resident #5's room along with a supply cart.
She stated the nurses had received education on Enhanced Barrier Precautions and donning personal protective equipment (PPE) and were aware of the policy.
She stated further education would be provided.
During an interview on 4/24/25 at 2:00 PM the Director of Nursing (DON) stated staff had been trained on Enhanced Barrier Precautions and were aware that personal protective equipment including gloves, gown, and masks were required when providing direct care such a tracheostomy care.
She stated Nurse #3 should have donned a gown along with gloves and a mask prior to providing care.
She stated education would be provided.
Review of Nurse #1's employee record verified she was hired by the facility on 1/10/25 as an agency licensed practical nurse (LPN).
There was no evidence of competency and training regarding j-tubes in her file.
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Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 345507 B.
Wing 04/24/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Autumn Care of Myrtle Grove 5725 Carolina Beach Road Wilmington, NC 28412
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.